| **Patient: Sarah Johnson, DOB: 03/15/1978, MRN: 12345678** |
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| **CHIEF COMPLAINT:** Chest pain and shortness of breath |
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| **HISTORY OF PRESENT ILLNESS:** |
| Sarah Johnson is a 45-year-old female who presents to the emergency department with acute onset chest pain that began approximately 2 hours ago. The patient describes the pain as sharp, substernal, radiating to her left arm and jaw. She rates the pain as 8/10 in intensity. The patient also reports associated shortness of breath, diaphoresis, and nausea. No recent trauma or exertion prior to symptom onset. |
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| **PAST MEDICAL HISTORY:** |
| - Hypertension diagnosed 2019 |
| - Type 2 Diabetes Mellitus since 2020 |
| - Hyperlipidemia |
| - Family history of coronary artery disease (father deceased at age 58 from myocardial infarction) |
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| **MEDICATIONS:** |
| - Lisinopril 10mg daily |
| - Metformin 1000mg twice daily |
| - Atorvastatin 40mg daily |
| - Aspirin 81mg daily |
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| **ALLERGIES:** Penicillin (causes rash) |
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| **SOCIAL HISTORY:** |
| Former smoker (quit 5 years ago, 20 pack-year history). Drinks alcohol socially. Works as an accountant. |
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| **VITAL SIGNS:** |
| - Temperature: 98.6°F (37°C) |
| - Blood Pressure: 165/95 mmHg |
| - Heart Rate: 102 bpm |
| - Respiratory Rate: 22/min |
| - Oxygen Saturation: 96% on room air |
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| **PHYSICAL EXAMINATION:** |
| GENERAL: Alert, oriented, appears anxious and in moderate distress |
| CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs, or gallops |
| PULMONARY: Bilateral breath sounds clear, no wheezes or rales |
| ABDOMEN: Soft, non-tender, no organomegaly |
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| **DIAGNOSTIC TESTS:** |
| - ECG: ST-elevation in leads II, III, aVF consistent with inferior STEMI |
| - Troponin I: 15.2 ng/mL (elevated, normal <0.04) |
| - CK-MB: 45 U/L (elevated) |
| - CBC: WBC 12,500, Hgb 13.2, Plt 285,000 |
| - BMP: Glucose 180 mg/dL, Creatinine 1.1 mg/dL |
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| **ASSESSMENT AND PLAN:** |
| 45-year-old female with acute ST-elevation myocardial infarction (STEMI) involving the inferior wall. |
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| 1. **Acute STEMI** - Patient meets criteria for urgent cardiac catheterization |
| - Emergent cardiac catheterization and PCI |
| - Dual antiplatelet therapy: Aspirin 325mg + Clopidogrel 600mg loading dose |
| - Heparin per protocol |
| - Metoprolol 25mg BID when hemodynamically stable |
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| 2. **Diabetes management** - Continue home Metformin, monitor glucose closely |
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| 3. **Hypertension** - Hold Lisinopril temporarily, restart when stable |
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| **DISPOSITION:** Patient transferred to cardiac catheterization lab for emergent intervention. |
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| **FOLLOW-UP:** Cardiology consultation, diabetes education, smoking cessation counseling |
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| --- |
| Dr. Michael Chen, MD |
| Emergency Medicine |
| General Hospital |
| Date: 06/10/2025, Time: 14:30 |
